INSTRUCTOR GUIDE FOR TACTICAL EVACUATION CARE IN TCCC-MP 150603 1
Tactical Combat Casualty Care
for Medical Personnel
03 June 2015
1.
Tactical Combat Casualty Care
for Medical Personnel
150603
Tactical Evacuation Care
Tactical Evacuation Care
The Tactical Evacuation phase of care is that phase in which
casualties are moved from the hostile and austere tactical environment
in which they were injured to a more secure location capable of
providing advanced medical care.
The term “Tactical Evacuation” includes both CASEVAC and
MEDEVAC as we will discuss.
This phase may represent the first opportunity to receive additional
medical personnel and equipment beyond that provided in Tactical
Field Care.
OBJECTIVES
 DESCRIBE the differences between
MEDEVAC and CASEVAC
2.
 DESCRIBE the differences between
Tactical Field Care and Tactical Evacuation
Care
Read text
 DESCRIBE the additional assets that may
be available for airway management and
electronic monitoring
OBJECTIVES
3.
 DISCUSS the indications for and
administration of Tranexamic Acid during
tactical evacuation
 DISCUSS the management of
moderate/severe TBI during tactical
evacuation
Read text
INSTRUCTOR GUIDE FOR TACTICAL EVACUATION CARE IN TCCC-MP 150603 2
Tactical Evacuation
4.
 Casualties need evacuation as soon as
feasible after significant injuries.
 Evacuation asset may be a ground vehicle,
aircraft, or boat.
 Evacuation time is highly variable –
significant delays may be encountered.
 Tactical situation and hostile threat to
evacuation platforms may differ markedly
from one casualty scenario to another.
 The Tactical Evacuation phase allows for
additional medical personnel and equipment
to be used.
Evacuation Terminology
5.
 MEDEVAC: evacuation using special
dedicated medical assets marked with a Red
Cross
– MEDEVAC platforms are non-combatant
assets
 CASEVAC: evacuation using non-medical
platforms
– May carry a Quick-Reaction force and
provide close air support as well
 Tactical Evacuation (TACEVAC) – this term
encompasses both types of evacuation above
Casualty movement/evacuation may occur as a separate moving
portion of the operation while the main assault force continues tactical
operations or the casualties may be evacuated along with the main
assault force as it exfiltrates from the main objective.
Pre-mission planning should identify medical facilities and
capabilities within the area of operations. Transport times to these
facilities by various types of vehicles should also be identified.
Planning for loading casualties onto mission vehicle assets is
important. A single litter patient may occupy space within a tactical
vehicle normally occupied by 4 uninjured combatants. Take this into
account during planning.
Any platform can be used to evacuate casualties. You must
understand the capabilities and limitations of any vehicle you opt to
utilize.
MEDEVAC vehicles and aircraft are specifically configured for
casualty care and designated with a Red Cross. These assets are
generally minimally armed. They will often NOT evacuate casualties
where there is a high threat of hostile fire.
CASEVAC assets are combatant platforms – good firepower, good
armor, no Red Cross, designed to go into the fight. You will need
CASEVAC assets if you have to evacuate casualties from a tactical
situation where the threat level is high.
INSTRUCTOR GUIDE FOR TACTICAL EVACUATION CARE IN TCCC-MP 150603 3
Aircraft Evacuation Planning
6.
 Flying rules vary widely among different
aircraft and units
 Consider:
–Distances and altitudes involved
–Day versus night
–Passenger capacity
–Hostile threat
–Medical equipment
–Medical personnel
–Icing conditions
In tactical situations where the threat of hostile fire is high, plan to use
a CASEVAC asset.
However, in general, if the tactical situation will allow for a
MEDEVAC asset to be used, it’s best to use that asset and save the
CASEVAC assets for other contingencies that may arise later.
If you use a tactical CASEVAC asset, you may have to make plans to
augment its medical capabilities. Plan to have extra medical personnel
and equipment on the CASEVAC platform.
Aircraft Evacuation Planning
7.
• Ensure that your evacuation plan includes
aircraft capable of flying the missions you
need
• Plan for primary, secondary, & tertiary
options
Always have a backup plan. Or two.
KNOW the flying rules for all of your potential evacuation aircraft.
CASEVAC vs. MEDEVAC: The Battle of
the Ia Drang Valley
8.
 1st Bn, 7th Cavalry in Vietnam
 Surrounded by 2000 NVA - heavy
casualties
 Called for MEDEVAC
 Request refused because landing zone was
not secure
 Eventual pickup by 229th Assault
 Helo Squadron after long delay
 Soldiers died because of this mistake
 Must get this part right
Here’s an example of how preventable deaths can occur from
evacuation delays if you don’t understand the difference between a
CASEVAC and a MEDEVAC.
Soldiers died because of this planning error.
INSTRUCTOR GUIDE FOR TACTICAL EVACUATION CARE IN TCCC-MP 150603 4
Ground Vehicle Evacuation
Ground evac typically took too long in Afghanistan.
9.
• More prevalent in urban-centric operations in
close proximity to a medical facility
• Vehicles may be organic to the unit or
designated MEDEVAC assets
Tactical Evacuation Care
10.
• TCCC guidelines for care are largely the
same in TACEVAC as they are in Tactical
Field Care.
• There are some changes that reflect the
additional medical equipment and personnel
that may be present in the TEC setting.
• This section will focus on those differences.
Airway in TACEVAC
11.
• Additional Options for Airway Management
– Supraglottic airway
– Endotracheal Intubation
• Confirm ETT placement with CO2
monitoring
• These airways are advanced skills not
taught in the basic TCCC course
Also, military vehicles are not designed for comfort. There is usually
significant noise and vibration in cargo areas, and overland movement
generally provides for an extremely rough ride, which may be hard on
the casualty.
The Tactical Evacuation phase may present the first opportunity
within the tactical operation to bring additional medical equipment
and personnel to bear.
Additional medical personnel should arrive with the evacuation asset.
This is important because:
-The unit’s medic or corpsman may be among its casualties
-The unit’s medic or corpsman may be dehydrated, hypothermic, or
otherwise debilitated
-The unit’s medic or corpsman may need to continue on the unit’s
mission and not get on the evacuation platform
-There may not have been a medic or corpsman at the casualty
scene
The Nasopharyngeal Airway adjunct was described in the Tactical
Field Care section. Once a casualty has been secured aboard an
evacuation platform, a wider variety of more definitive airway
adjuncts and personnel trained to use them may be available, although
the NPA should suffice for most patients.
A number of supraglottic airways can be used in the Tactical
Evacuation setting. They are easier and faster to insert than an ET
tube, are less likely to harm the casualty if not correctly placed, and
require less training and experience to use successfully. Endotracheal
intubation, though, may still be a better airway option for certain
patients.
Don’t attempt advanced airways unless you have been trained on
them and are proficient in their use.
INSTRUCTOR GUIDE FOR TACTICAL EVACUATION CARE IN TCCC-MP 150603 5
Breathing in TACEVAC
12.
 Watch for tension pneumothorax as
casualties with a chest wound ascend to the
lower pressure at altitude.
 Pulse ox readings will become lower as
casualty ascends unless supplemental oxygen
is added.
 Chest tube placement may be considered if a
casualty with suspected tension pneumo fails
to respond to needle decompression
Consider tension pneumothorax in casualties with penetrating chest
injuries and progressive respiratory distress. Decompress with a
needle thoracostomy.
Although chest tubes may be considered by trained personnel in long
or delayed evacuations, they are considerably more difficult and
invasive procedures, and there is no evidence that they are more
effective than needle decompression for relieving tension
pneumothorax.
Supplemental Oxygen in
Tactical Evacuation Care
13.
Most casualties do not need supplemental
oxygen, but have oxygen available and use it
for:
– Casualties in shock
– Low oxygen sat on pulse ox
– Unconscious casualties
– Casualties with TBI
(maintain oxygen saturation > 90%)
– Chest wound casualties
Oxygen should be pre-positioned on evacuation assets.
Oxygen generators or concentrators are preferred over compressed
gas cylinders because of the reduced explosive hazard.
5. Tranexamic Acid (TXA)
14.
If a casualty is anticipated to need significant
blood transfusion (for example: presents with
hemorrhagic shock, one or more major
amputations, penetrating torso trauma, or
evidence of severe bleeding)
– Administer 1 gram of tranexamic acid
(TXA) in 100 cc Normal Saline or
Lactated Ringer’s as soon as possible but
NOT later than 3 hours after injury.
– Begin second infusion of 1 gm TXA after
Hextend or other fluid treatment.
If the casualty meets the criteria for treatment with TXA, and it has
not already been given, then give the first dose in Tactical Evacuation
Care. Note that TXA should not be initiated if more than three
hours have passed since the casualty was injured.
INSTRUCTOR GUIDE FOR TACTICAL EVACUATION CARE IN TCCC-MP 150603 6
TXA Administration – 2nd Dose
15.
• Typically given after the casualty arrives at a
Role II/Role III medical facility.
• May be given in Tactical Evacuation Care if
the first dose was given earlier, and fluid
resuscitation has been completed before
arrival at the medical facility.
– Should NOT be given with Hextend or
through an IV line with Hextend in it
– Inject 1 gram of TXA into a 100-cc bag of
normal saline or lactated Ringer’s
– Infuse slowly over 10 minutes
Tactical Evacuation Care Guidelines
Remember that rapid IV push of TXA may cause hypotension.
If there is a new-onset drop in BP during the infusion – SLOW
DOWN the TXA infusion.
Read text
6. Traumatic Brain Injury
a. Casualties with moderate/severe TBI
should be monitored for:
16.
1. Decreases in level of consciousness
2. Pupillary dilation
3. SBP should be >90 mmHg
4. O2 sat > 90
Continued…
Unilateral pupillary dilitation accompanied by a decrease in the level
of consciousness may indicate that intracranial pressure is rising and
that cerebral herniation is imminent. Casualties with moderate/severe
TBI should be watched closely for these signs.
Hypotension and hypoxemia may worsen outcomes for casualties
with moderate/severe TBI. These conditions should be watched for
and prevented or corrected as quickly as possible.
INSTRUCTOR GUIDE FOR TACTICAL EVACUATION CARE IN TCCC-MP 150603 7
Read text
Hypothermia may result in coagulation defects that may be associated
with increased mortality in trauma victims with moderate to severe
brain injury. It, too, should be prevented or corrected as quickly as
possible in these patients.
Tactical Evacuation Care Guidelines
6. Traumatic Brain Injury
a. Casualties with moderate/severe TBI
should be monitored for:
17.
5. Hypothermia
6. PCO2 (If capnography is available,
maintain between 35-40 mmHg)
7. Penetrating head trauma (if present,
administer antibiotics)
8. Assume a spinal (neck) injury until
cleared
Continued…
Hypercapnia (elevated level of CO2 in the blood) contributes to an
increase in cerebral blood flow which in turn contributes to elevation
of the intracranial pressure (ICP). Elevated ICP must be avoided as
this may lead to cerebral herniation. It is important, then, to keep CO2
from rising in casualties with injured brains. On the other hand,
hypocapnia leads to cerebral vasoconstriction and decreased cerebral
blood flow, which can also be bad for the casualty in that it reduces
the amount of oxygen supplied to the brain. It is important, then, to
maintain normal CO2 levels in casualties with injured brains (unless
signs of cerebral herniation appear – more on that just ahead).
Capnography should be used to monitor the casualty’s end-tidal CO2
to make sure that respiration remains adequate to keep the blood level
of CO2 in the normal range.
With respect to wound infection, a penetrating injury to the brain is
the same as a penetrating injury to any other tissue. Early
administration of an antibiotic may help prevent infection.
If an injury to the head is severe enough to cause brain injury, then
there was enough energy involved to cause injury to the cervical spine
as well. Therefore, in cases of moderate/severe TBI, cervical spine
fracture should be presumed, and appropriate precautions taken, until
the spine is cleared for injury.
INSTRUCTOR GUIDE FOR TACTICAL EVACUATION CARE IN TCCC-MP 150603 8
Tactical Evacuation Care Guidelines
6. Traumatic Brain Injury
18.
b. Unilateral pupillary dilation accompanied
by a decreased level of consciousness may
signify impending cerebral herniation; if
these signs occur, take the following
actions to decrease intracranial pressure:
1. Administer 250cc of 3% or 5%
hypertonic saline bolus
2. Elevate the casualty’s head 30 degrees
Read text
Rising ICP may lead to cerebral herniation. When signs of herniation
are present in a brain-injured casualty, rapid reduction is the ICP is
needed.
Hypertonic saline may help decrease ICP and improve cerebral
perfusion pressure and brain tissue oxygen levels.
Elevation of the casualty’s head may help reduce ICP.
Continued…
Tactical Evacuation Care Guidelines
6. Traumatic Brain Injury
b. (Continued)
3) Hyperventilate the casualty
a) Respiratory rate 20
b) Capnography should be used to
maintain the end-tidal CO2
between 30-35 mmHg
c) The highest concentration of
oxygen (FIO2) possible should be
used for hyperventilation
19.
Continued…
Read text
Hyperventilation leads to reduced levels of CO2 in the blood that, in
turn, can contribute to cerebral vasoconstriction and lowered ICP.
Therefore, hyperventilation can be used as a temporary measure to
lower ICP in brain-injured casualties exhibiting signs of cerebral
herniation. If capnography is available, it should be used to monitor
end-tidal CO2 levels. The target range for CO2 is slightly lower than
normal.
Hyperoxia also contributes to cerebral vasoconstriction that will
reduce cerebral blood flow which may help reduce elevated ICP.
However, because of the increased amount of oxygen carried by the
blood when hyperoxic, it will improve cerebral tissue oxygenation
even while reducing cerebral blood flow. If oxygen is available, the
highest concentration that can be delivered should be delivered.
Tactical Evacuation Care Guidelines
Read text
6. Traumatic Brain Injury
Notes:
20.
- Do not hyperventilate unless signs of
impending herniation are present.
- Casualties may be hyperventilated with
oxygen using the bag-valve-mask technique.
The hypocarbia and cerebral vasoconstriction that result from
hyperventilation may be harmful to a brain-injured casualty who is
not herniating. These casualties need to maintain their cerebral
perfusion. Accordingly, hyperventilation should only be used in
casualties who display signs of cerebral herniation, and who need
emergent reduction in ICP.
INSTRUCTOR GUIDE FOR TACTICAL EVACUATION CARE IN TCCC-MP 150603 9
Hypothermia Prevention in TACEVAC
Hypothermia Prevention
in TACEVAC
21.
Remember to keep the casualty on an insulated surface or get
him/her on one as soon as possible.
Apply the Ready-Heat Blanket from the Hypothermia Prevention
and Management Kit (HPMK), to the casualty’s torso (not
directly on the skin) and cover the casualty with the HeatReflective Shell (HRS).
Remember to keep the casualty on an insulated
surface or get him/her on one as soon as
possible.
Apply the Ready-Heat Blanket from the
Hypothermia Prevention and Management Kit
(HPMK), to the casualty’s torso (not directly
on the skin) and cover the casualty with the
Heat-Reflective Shell (HRS).
Read text
Hypothermia Prevention in TACEVAC
Hypothermia Prevention
in TACEVAC
If an HRS is not available, the previously recommended combination
of the Blizzard Survival Blanket and the Ready Heat blanket may also
be used.
22.
Use a portable fluid warmer capable of warming all IV fluids including
blood products.
If an HRS is not available, the previously
recommended combination of the Blizzard
Survival Blanket and the Ready Heat blanket
may also be used.
Use a portable fluid warmer capable of
warming all IV fluids including blood products.
Remember: Prevention of Hypothermia in
Helicopters!
23.
Read text
• Cabin wind and altitude cold result in cold
stress
• Protection especially important for
casualties in shock and burn casualties
Imagine how cold these casualties are. It is always cold at altitude in
helos, but much worse in winters.
Medics and corpsmen in helicopters in winter – bring chemical
hand warmers to maintain manual dexterity!
INSTRUCTOR GUIDE FOR TACTICAL EVACUATION CARE IN TCCC-MP 150603 10
Tactical Evacuation Care Guidelines
Tactical Evacuation Care Guidelines
18. CPR in TACEVAC Care
24.
a. Casualties with torso trauma or polytrauma
who have no pulse or respirations during
TACEVAC should have bilateral needle
decompression performed to ensure they do
not have a tension pneumothorax. The
procedure is the same as described in section
2 above.
18. CPR in TACEVAC Care
a. Casualties with torso trauma or
polytrauma who have no pulse or
respirations during TACEVAC should
have bilateral needle decompression
performed to ensure they do not have a
tension pneumothorax. The procedure is
the same as described in section 2 above.
As in Tactical Field Care, when a polytrauma or torso trauma victim
loses signs of life during resuscitation, bilateral needle decompression
of the chest should be performed, if feasible, to rule out tension
pneumothorax.
Tactical Evacuation Care Guidelines
Tactical Evacuation Care Guidelines
18. CPR in TACEVAC Care
25.
b. CPR may be attempted during this phase of care
if the casualty does not have obviously fatal
wounds and will be arriving at a facility with a
surgical capability within a short period of time.
CPR should not be done at the expense of
compromising the mission or denying lifesaving
care to other casualties.
18. CPR in TACEVAC Care
b. CPR may be attempted during this phase
of care if the casualty does not have
obviously fatal wounds and will be
arriving at a facility with a surgical
capability within a short period of time.
CPR should not be done at the expense
of compromising the mission or denying
lifesaving care to other casualties.
TACEVAC CARE - Hoisting
26.
• Rigid Litters Only When Hoisting!
• Check and double-check rigging
CPR may be considered during TACEVAC if it is tactically and
practically feasible, and surgical care is not far away.
Stokes or basket-type litters should be used for hoisting casualties into
helos.
Secure the casualty – check and double-check rigging.
INSTRUCTOR GUIDE FOR TACTICAL EVACUATION CARE IN TCCC-MP 150603 11
27.
Questions?
TACEVAC Care for Wounded Hostile
Combatants
28.
• Principles of care are the same for all
wounded combatants
• Rules of Engagement may dictate
evacuation process
• Restrain and provide security
• Remember that each hostile casualty
represents a potential threat to the provider
and the unit and take appropriate measures
• They still want to kill you.
We talked about this in TFC.
Maintain proper prisoner handling procedures.
Tactical Evacuation Care Summary of Key
Points
29.
• Evacuation time is highly variable
• Thorough planning is key
• Similar to Tactical Field Care guidelines but
with some modifications
Read text
INSTRUCTOR GUIDE FOR TACTICAL EVACUATION CARE IN TCCC-MP 150603 12
Convoy IED Scenario
30.
Recap from TFC
The last medical interventions during TFC
were:
– Placed tourniquet on both bleeding stumps
– Disarmed
– Placed NPA
– Established IV
– Administered 1 gm TXA and I unit whole
blood
– IV antibiotics
– Provided hypothermia prevention
• Your helo has now arrived at the HLZ
Read text
OK – let’s go back to our scenario that we started in Care Under Fire.
Your element was in a five-vehicle convoy moving through a small
Iraqi village when a command-detonated IED exploded under the
second vehicle. The person next to you sustained bilateral mid-thigh
amputations. He had heavy arterial bleeding from the left stump, and
the right stump was only mildly oozing blood. The care you rendered
during Tactical Field Care is shown here. The time in flight to the
hospital will be 30 minutes.
Convoy IED Scenario
31.
32.
What’s Next?
• Casualty is now conscious but is confused
• Reassess casualty for ABCs
– NPA still in place
– Tourniquets in place, no significant
bleeding
• Attach electronic monitoring to casualty
– Heart rate 140; systolic BP 70
– O2 sat = 90%
Convoy IED Scenario
What’s next?
• Supplemental Oxygen
– Why?
• Casualty is still in shock
What’s next?
• Continue fluid resuscitation with plasma
and RBCs in a 1:1 ratio
– Why?
• Casualty is still in shock
Read text
Read text
INSTRUCTOR GUIDE FOR TACTICAL EVACUATION CARE IN TCCC-MP 150603 13
Convoy IED Scenario
33.
34.
What’s next?
• Inspect and dress known wounds and search
for additional wounds
What’s next?
• Try to Remove tourniquets and use
hemostatics?
–No
–Why? THREE reasons:
• Short transport time - less than 2 hours
from application of tourniquets
• No distal extremities to lose
• Casualty is in shock
Questions/Comments?
Read text